Asian Cardiovasc Thorac Ann 1999;7:326-328
© 1999 Asia Publishing EXchange Pte Ltd
Endobronchial Inflammatory Pseudotumor: A Cause of Chronic Cough
Zeki Yildirim, MD,
Ömer Soysal, MD,1,
Münire Gökirmak, MD,
Hasan Berat Cihan, MD,2,
Bülent Mizrak, MD,3,
H Canan Hasano
lu, MD
Department of Pulmonary Diseases
1 Department of Thoracic Surgery
2 Department of Cardiovascular Surgery
3 Department of Pathology University of Inönü School of Medicine Turgut Özal Medical Center Malatya, Turkey
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For reprint information contact: Zeki Yildirim, MD Tel: 90 422 341 0785 Fax: 90 422 341 0610 email: zekiy{at}hotmail.com University of Inönü School of Medicine, Turgut Özal Medical Center, Malatya 44100, Turkey.
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Abstract
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Endobronchial location of an inflammatory pseudotumor is extremely rare. A 48-year-old female presented with chronic cough. An endobronchial polypoid inflammatory pseudotumor was diagnosed by bronchoscopic biopsy and treated by a middle lobectomy.
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Introduction
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Inflammatory pseudotumor (IP) of the lung is an uncommon benign pulmonary tumor of unknown cause, which generally involves only the lung parenchyma.1 Endobronchial involvement is extremely rare.2–4 An IP can be asymptomatic or characterized by variable clinical expressions.5 We report a case of endobronchial IP presenting as chronic cough.
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Case Report
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A 48-year-old female was admitted with a complaint of chronic cough for one year. The cough worsened at night and during passive exposure to cigarette smoke. The patient had no history of sputum expectoration, hemo-ptysis, dyspnea, fever, or chest pain. She was previously given a ß2-mimetic inhaler and a corticosteroid inhaler, without benefit. The patient had no prior illnesses, she was on no other medication such as angiotensin converting enzyme inhibitors, and had no known environmental irritant exposure. She had never smoked cigarettes or abused alcohol or drugs.
Physical examination of the patient was normal. Bronchial asthma was suspected but pulmonary function tests revealed normal values for forced vital capacity (107% of predicted) and forced expiratory volume in one second (80% of predicted). Serial measurements of peak expiratory flow showed a variability of less than 20%. A linear density in the right lower zone was seen on a chest radiograph (Figure 1
). Computed tomography of the chest showed infiltration of the middle lobe of the right lung (Figure 2). On bronchoscopic examination, a gray white polypoid lesion was observed, partially obstructing the orifice of the right middle lobe bronchus. The polypoid lesion was mobile and the surrounding bronchial mucosa was normal. No abnormality was observed in the other bronchi. Histo-pathology of a specimen obtained by bronchoscopic biopsy showed IP with tissue fragments covered by ciliated epithelium and composed of mesenchymal cells with spindle nuclei. The patient underwent a posterolateral thoracotomy. Although atelectasis of the middle lobe was not detected by preoperative radiography, the medial segment of the middle lobe was seen to be atelectatic during the operation, so it was resected. Pathological diagnosis of the lobectomy material agreed with that of the bronchoscopic biopsy (Figures 3 and 4). The patient was discharged on postoperative day 5 and her cough subsided after the operation.
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Figure 3. Tissue specimen from resected material. Bronchial cartilage is seen in the left lower area (hematoxylin and eosin stain, original magnification x20).
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Figure 4. Higher magnification of the resected material. Spindle cells mixed with scattered inflammatory cells are seen (hematoxylin and eosin stain, original magnification x50).
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Discussion
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IP is a rare pathological entity that has many synonyms of which the most common is plasma cell granuloma. Other terms that have been used are postinflammatory tumor of the lung, histiocytoma of the bronchus, benign histiocytic tumor, vascular endothelioma, plasmacytoma, inflammatory fibrous histiocytoma, fibrous histiocytoma, and inflammatory myofibroblastic tumor (plasma cell granuloma). Although the lungs are most frequently involved, other organs can also be affected.6 The etio-pathology is unknown. Most IPs are located in the lung parenchyma; endobronchial location has been reported very rarely.1–4 An IP may be asymptomatic or associated with chest pain, fever, chronic cough, hemoptysis, intermittent blood-streaked sputum, arthralgias, fatigue, and difficulty in breathing.5,6 The patient may have a history of recurrent pneumonia or signs of asthma, pneumothorax, or empyema.6 The presence of these symptoms and signs depends principally on the size and location of tumor.
Endobronchial IP frequently has a clinical manifestation of respiratory obstruction with atelectasis as a radiological sign, allowing detection at an early age.7 Since the lesion in our patient did not obstruct the bronchus completely, signs of atelectasis were not present. The patient was treated with ß2-mimetic and corticosteroid inhalers because her chronic cough was thought to be a variant of asthma. Thus, the diagnosis was delayed for almost a year. The endobronchial lesion was eventually diagnosed by bronchoscopic examination. However, bronchoscopic biopsy of an IP may not provide a diagnosis; in previously reported cases, the disease was usually diagnosed in specimens obtained surgically.3,7
Pulmonary inflammatory pseudotumor is typically a solitary peripheral sharply circumscribed mass with an anatomic bias for the lower lobes. Local invasion and primary involvement of the mediastinum and hilar structures are unusual manifestations.8 In our patient, the chest radiograph was almost normal except for a linear infiltration. A computed tomography scan of the chest did not show any additional pathologic involvement of the tumor. Treatment of endobronchial IP is by surgical resection; lobectomy, conservative wedge resection, or segmental resection may be appropriate. If the distal lung tissue is normal, bronchotomy and excision of the lesion may be preferred. As the medial segment of the right middle lobe was atelectatic in our patient, a right middle lobectomy was necessary. The disease has an excellent prognosis; recurrence of the lesion or death due to IP are rarely seen. This case of endobronchial inflammatory pseudotumor of the lung is reported to emphasize that the disease should be considered in the differential diagnosis of chronic cough.
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References
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Abstract
Introduction
